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The King’s Fund’s latest survey of NHS performance in England paints a picture of a service struggling to cope with increasing demands at a time of unprecedented resource constraint. The pressures on the NHS are greatest at the front doors of hospitals, with waiting times in emergency departments the longest they have been in a decade. The prime minister’s pledge to maintain the commitment to treat 95% of patients within four hours in emergency departments was broken in the first quarter of 2013, a clear and worrying signal of what lies ahead.